Septocutaneous gluteal artery perforator (sc-GAP) flap for breast reconstruction: how we do it different clinical implications, particularly with respect to the S-GAP flap. The evolution from the S-GAP (superior gluteal artery perforator) flap to the sc-GAP (septocutaneous gluteal artery perforator) flap reflects the above mentioned concept. We published a preliminary anatomical study12 and later on a clinical study13 on this concept showing that the use of septocutaneous perforators can make the dissection of the flap easier with an improvement in the aesthetic results of the donor site. TOPOGRAPHICAL AND FUNCTIONAL ANATOMY OF THE GLUTEAL REGION This paragraph is partly based on Gray’s Anatomy,14 Moore Clinically Oriented Anatomy15 and Stone and Stone’s Atlas of Skeletal Muscles.16 The gluteal region or buttock is bounded cranially by the iliac crest and caudally by the oblique border of the gluteus maximus muscle. The hori- zontal skin fold of the buttock, indicated as gluteal fold (sulcus glutealis, ruga glutealis horizontalis), is often mistaken for this caudal border. It is important clinically to define the exact borders of the gluteal region in order to achieve skin projections of underlying bony landmarks, muscles, nerves and blood vessels as accurately as possible. The crena analis or crena ani is the vertical cleft, leading to the anus, between the left and right buttock. It is also called (crena) clunium, gluteal furrow, intergluteal or natal cleft, rima ani or rima clunium. Besides the iliac crest, the anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS), at the beginning and end of the iliac crest, are important bony landmarks. The PSIS is marked by a skin dimple. Caudomedially the ischial tuberosity can be palpated, deep to the gluteus maximus muscle. Laterally the greater trochanter is an important, palpable landmark. The prominence of the buttock is not only formed by the gluteus maximus muscle, but in the craniolateral part also by the gluteus medius. In the gluteal region two muscle layers can be distinguished: (1) a superficial layer containing the gluteus maximus, and (2a-e) a deep layer containing the gluteus medius, gluteus minimus, piriformis, triceps coxae and quadratus femoris muscles (fig 6.1). The gluteus muscles are mainly extensors and abductors in the hip joint, the piriformis, triceps coxae and quadratus femoris are mainly lateral rotators. (1) The gluteus maximus muscle is the largest, thickest and most superficial muscle in the buttock. It originates from the outer surface of the ilium, dorsally from the posterior gluteal line, from the adjacent dorsal surface of the lower sacrum and from the lateral coccyx. Connective tissue muscle origins are the sacrotuberal ligament, the erector spinae aponeurosis and the 84
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